Perioperative management - Uniportal VATS mediastinal lymphadenectomy right

• Material acquisition for pretherapeutic staging

Clarification of the mediastinal lymph node status in cases of imaging morphological abnormalities and negative fine needle aspiration using endobronchial ultrasound.

• In the context of lung resection

During the operation of a lung carcinoma, systemic lymph node dissection is required. This involves the removal of mediastinal tissue along with the lymph nodes contained within, following anatomical structures.

• Lack of cardiopulmonary reserve for lung ventilation
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic plan regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

In cases of clinical suspicion of bronchial carcinoma, a contrast-enhanced computed tomography of the thorax and upper abdomen with visualization of the liver (with portal venous phase) and adrenal glands should be performed. The addition of preoperative diagnostics with FDP-PET-CT diagnostics significantly improves lymph node diagnostics.

In a curative treatment strategy, histological clarification should be performed if changes in the mediastinal lymph nodes are detected in imaging. Initially, a fine needle aspiration using endobronchial ultrasound should be performed. If no malignancy is detectable despite morphologically conspicuous lymph nodes, a surgical procedure, such as VATS lymph node resection or mediastinoscopy with lymph node biopsy, should be performed.

Note: Tumor involvement of the mediastinal lymph nodes represents an N2 involvement and is classified as at least stage IIIa according to the UICC classification. Here, in addition to primary surgery, a multimodal therapy concept is possible, and the therapy algorithm in the guideline is not yet definitively defined. Treatment in centers and within the framework of studies is recommended.

• Shaving of the right thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Injury to adjacent structures, particularly the trachea and main bronchi, large vessels, and the esophagus, necessitating corresponding extension of the procedure
• Damage to the phrenic nerve with diaphragmatic elevation on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paralysis on the affected side
• Postoperative air fistula due to mobilization-related lesions of the lung parenchyma
• Postoperative bronchial fistula due to thermal damage requiring intervention, possibly including surgical treatment
• Postoperative lymph fistula with chylothorax
• Postoperative hemorrhage with potentially necessary re-operation
• Cardiac arrhythmias
• Positioning injuries

Treatment alternative: Endobronchial fine needle aspiration